Leeds Autism Services New Mabgate Centre Inspection report 16 Church Road Armley Leeds West Yorkshire LS12 1TZ Date of inspection visit: 12 August 2016 Date of publication: 12 September 2016 Tel: 01132635120 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? 1 New Mabgate Centre Inspection report 12 September 2016
Summary of findings Overall summary The inspection took place on 05, 07 July and 12 August 2016 and was announced. We carried out an inspection in January 2014, where we found the provider was meeting all the regulations we inspected. New Mabgate Centre provides one to one vocational and education support at the location and within the wider community for adults with autism related conditions. They also provide personal care for one person in their own home. The service did not have a registered manager at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A family member told us their relative was safe with staff and when they attended the New Mabgate Centre and we saw there were systems and processes in place to protect people from the risk of harm. Staff had a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe. There were appropriate arrangements for the management of medicines. Individual risks had been assessed and identified as part of the support and care planning process. We found there were, sufficient numbers of experienced staff. Robust recruitment and selection procedures were in place. Staff received the training required to meet people's needs and had attended supervision meetings, however, supervisions were not carried out in line with the provider's policy and there was no mechanism for monitoring what staff training still needed to be completed. We have made a recommendation about staff training and supervision. People's needs were assessed and care and support was planned and delivered in line with their individual care needs. Staff had good relationships with the person who used the service and family members. Staff knew how to respect people's privacy and dignity. We saw staff were kind and supported people with patience. Staff said people were supported to make decisions. Staff told us people received the support they needed with meals and healthcare. Daily routines were in place and an individual programme of activity which was carried out at the location or in the community. The service had good management and leadership. There were effective systems in place to monitor and improve the quality of the service provided. People and family members were given information on how to make a complaint. 2 New Mabgate Centre Inspection report 12 September 2016
The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? The service was safe. A family member told us their relative was safe with staff and when they attended the New Mabgate Centre and when personal care was provided. The staff we spoke with knew what to do if abuse or harm happened or if they witnessed it. Individual risks had been assessed and identified as part of the support and care planning process. We found medicines were well managed. There were enough staff to meet the person's needs. The provider had effective recruitment procedures in place. Is the service effective? The service was effective in meeting people's needs. We saw staff completed training; but, there was no mechanism for monitoring what training still needed to be completed. Staff had the opportunity to attend supervision; however, this was not always in line with the registered provider's policy. We have made a recommendation about staff training and supervision. Staff we spoke with told us how they supported people to make decisions. People's nutritional and health care needs were met. Is the service caring? The service was caring. A family member told us their relative was very happy with the care and support provided to them. Support was provided by staff who treated them with kindness and were respectful of their privacy and dignity. Staff knew the person they cared for well and were confident they received good care and their individual needs were met. Staff had developed good relationships with people. 3 New Mabgate Centre Inspection report 12 September 2016
Is the service responsive? The service was responsive to people's needs. People's needs were assessed before they began to use the service and care and support plans were developed from this information. Care and support plan we looked at contained sufficient and relevant information to provide consistent care and support. Daily routines were in place and people had an individual programme of activity. People and family members were given information on how to make a complaint Is the service well-led? The service was well-led. The management team were familiar with individual care and support needs and knew people who used the service, family members and staff very well. There were effective systems in place to monitor and improve the quality of the service provided. There were systems in place which allowed people who used the service and/or family members to provide feedback on the service provision. 4 New Mabgate Centre Inspection report 12 September 2016
New Mabgate Centre Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This inspection took place on 05, 07 July and 12 August 2016 and was announced. The provider was given 48 hours' notice because the location provides personal care to people who use the vocational and educational centre. The inspection team consisted of one adult social care inspector. We carried out this inspection over this period of time due to discussion regarding the registration of the service. At the time of this inspection there was one person receiving personal care from New Mabgate Centre. We spoke with one relative. We spoke with the relative due to the complex needs of the person who used the service. We also spoke with five members of staff, the acting team manager, deputy chief executive and the chief executive. We visited the vocational service and spent some time looking at documents and records that related to people's care and support and the management of the service. We looked at one person's care plan and support plan. Before the inspection, the provider had completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We sent out surveys to 23 members of staff and seven health professionals; seven from members of staff and one from a health professional were returned. We have included their responses in the inspection report. We also reviewed all the information we held about the service. This included any statutory notifications that had been sent to us and previous inspection reports. We contacted the local authority and Healthwatch. The local Authority stated they were not aware of any concerns with regards to this service. Healthwatch did not respond with any concerns. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. 5 New Mabgate Centre Inspection report 12 September 2016
Is the service safe? Our findings Before our inspection we asked staff and health professionals to complete a survey. Staff told us they would know what to do if they suspected one of the people they supported was being abused or was at risk of harm. They also said people who used the service were safe from abuse and/or harm from the staff of this service. Health professionals told us people who used the service were safe from harm from the staff of this service. Staff we spoke with could confidently identify different types of abuse, the different signs they would look for in people's behaviour which could identify they were being abused and knew what to do if they witnessed any incidents. Staff we spoke with told us they had received safeguarding training and the records showed some staff had completed safeguarding training. One staff member told us, "People are absolutely safe." Another staff member said, "People are safe, risk assessments are in place and I would be happy to take any concerns further if I needed to." A family member told us, "[Name of person] is definitely safe; I would not let them stay if they were not safe." The service had policies and procedures for safeguarding vulnerable adults and we saw the safeguarding policies were available and accessible to members of staff. Where action had been identified in response to a safeguarding incident we saw this had taken place. We asked in the PIR 'What improvements do you plan to introduce in the next 12 months that will make your service safer, and how will these be introduced? The provider stated 'Monitoring of safeguarding concerns to ensure concerns are dealt with effectively and are discussed at board level'. Staff were aware of the whistleblowing policy and how to report concerns outside the organisation. 'Whistleblowing' is when a worker reports suspected wrongdoing at work. The care plan and support plan we looked at showed the person had risks assessed appropriately and these were updated regularly and revised where necessary. We saw risk assessments had been carried out to cover activities and health and safety issues. There was guidance about what action staff needed to take in order to reduce or eliminate the risk of harm. This helped ensure people were supported to take responsible risks as part of their daily activity with the minimum necessary restrictions. There were systems in place to monitor accidents or incidents and we saw the service learnt from incidents to protect people from harm. Staff we spoke with told us there were enough staff on each shift and this enabled them to undertake their work. One staff member told us, "Plenty of staff and I am never left alone with anyone." Another staff member told us, "We use good agency staff sometimes that cover for sickness and leave. I am happy with the staffing levels." A third staff member said, "Generally speaking there are enough staff." On the day of our 6 New Mabgate Centre Inspection report 12 September 2016
inspection we saw there were sufficient staffing levels to support people with their activities and to keep people safe. A family member we spoke with told us, "The staff ratio is good." We reviewed the recruitment process to ensure appropriate checks had been made to establish the suitability of each candidate. We found recruitment practices were safe and the service had clear policies and procedures to follow. We saw relevant checks had been completed, which included a disclosure and barring service check (DBS) and references were obtained from previous employers. One staff member told us, "I was not able to start before my DBS was in place." The DBS is a national agency that holds information about criminal records. This helped to ensure people who used the service were protected from individuals who had been identified as unsuitable to work with vulnerable people. We looked at the systems in place for managing medicines and found there were appropriate arrangements in place for checking medication items into and out of the service. Adequate stocks of medicines were maintained to allow continuity of treatment. We saw all the medication was stored in a locked cupboard in a locked room. On receipt into the service, people's medication was placed into a sealed see through plastic container with the relevant person's name on. Appropriate arrangements were in place in relation to the recording of medicines. For recording the administration of medicines, medicine administration records (MARs) were used. The MAR showed staff were signing for the medication they were giving. The MAR contained details of medicines each person had brought with them to the service. We saw all the records relating to the administration of medications were completed correctly and accurately. One staff member told us, "I have watched the medication process and this is safe." Another staff member said, "Medication process is safe, everything is locked up and people have their own boxes." A third staff member told us, "Medication is as safe as it possibly could be. Everything is locked up and MAR charts are in place and signed." A fourth staff member said, "The medication is locked up and all signed for, I am happy with the process." Staff told us they had completed medicines training before they were able to administer medications and their competency was check during their induction. The record we saw confirmed this. The acting team manager told us 'spot checks' were carried out on the MAR's; however, these were not documented. They told us they would be implementing a recorded 'spot check' by the end of July 2016. 7 New Mabgate Centre Inspection report 12 September 2016
Is the service effective? Our findings In response to our survey, 86% of staff told us the training they received enabled them to meet people's needs and preferences. We looked at staff training records which showed staff had completed a range of training sessions, which were conducted either face to face or by e-learning. These included first aid, health and safety, infection control and food safety. We saw some staff also completed specialist training which helped support people who used the service. This included epilepsy awareness and conflict resolution. We saw training completed was recorded by month and by the individual staff member. There was an overview of what training had been completed and what still needed to be completed by members of staff. However, there were no mechanisms for monitoring what training had not been completed. For example, on the May 2016 records showed staff had not completed some of the training. The deputy chief executive told us, "The format of the training matrix needs altering so each type of training is on a tab which highlights staff training needs for each site." The acting team manager told us they had recently moved training systems to the 'virtual training college'. This system hosts individual staff members training requirements and generates automatic alerts for expiration of training. A family member told us, "Staff are trained appropriately." Staff told us they had completed lots of training, which included medication, fire safety, first aid, lone working and moving and handling. One staff member told us, "The training is relevant and helps me think about the job I am doing." Another staff member told us, "I am working through the Care Certificate at the moment." The 'Care Certificate' is an identified set of standards that health and social care workers adhere to in their daily working life. In our survey, 71% of staff agreed they received regular supervision and appraisal which enhanced their skills and learning. Health professionals told us staff were competent to provide the care and support required by people who used the service. During our inspection we spoke with members of staff and looked at staff files to assess how staff were supported to fulfil their roles and responsibilities. Staff confirmed they received supervision, during which they could discuss any issues on a one to one basis. When we looked in staff files we were able to see evidence each member of staff had received individual supervision. One staff member told us, "I have supervision about every six weeks and we talk about me." Another staff member said, "I have supervision every six weeks and have just had an annual appraisal." We saw staff had received an annual appraisal. We asked in the PIR, 'How do you ensure the service you provide is safe?' The provider stated 'Monthly supervision for staff which includes safeguarding concerns as a standard agenda item'. However, we noted the frequency of supervisions was not monthly or in line with the provider's policy. We recommend the provider determines what records are required to monitor staff training and review the staff supervision process to make sure it is in line with their policy. The acting team manager and the deputy chief executive told us they would review the way staff training was recorded and the frequency of supervisions immediately. 8 New Mabgate Centre Inspection report 12 September 2016
One staff member told us the induction programme included policies and procedure, shadowing and training. We asked in the PIR, 'How do you ensure the service you provide is safe?' The provider stated 'Robust staff induction which includes safeguarding, mental capacity and positive behaviour support/use of physical intervention. In our survey, staff said they completed an induction which prepared them fully for their role before they worked unsupervised. One staff member told us, "I had a four week induction, which included training, shadowing and an overview of the organisation." We looked at staff files and were able to see information relating to the completion of induction. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. In our survey, all staff told us they received training in and understood their responsibilities under the Mental Capacity Act (2005). Health professionals agreed the managers and staff understood their responsibilities under the Mental Capacity Act (2005). We saw from the records some staff had attended training and all the staff we spoke with had knowledge of the Mental Capacity Act 2005 (MCA). Staff explained people were able to make decisions about the care and support provided and the activities they wanted to do. Staff demonstrated an understanding of mental capacity. One staff member told us, "People are given as much choice as possible." Other comments included, "People are given choice and people can choose", "People have choice, aims and goals and these are recorded in the session plans" and "Decisions are made by the person and we give enough information to help them do that. We offer support for people to make decisions." People's nutritional needs were assessed during the care and support planning process and we saw people's likes, dislikes and any allergies had been recorded in their care and support plan. Staff we spoke with told us people usually brought a packed lunch or ate out. Staff comments included, "People bring packed lunches or sometimes they like to eat out", "We sometimes eat out depending on the activity" and "Most people bring their lunch or sometimes I support people with cooking. We asked a family member about the arrangements for their relative's lunch. They told us, "[Name of person] takes a packed lunch and they have started cooking with her." Staff told us if people became unwell they would contact the person's family member or place of residence. If they thought the person's condition was serious they would not hesitate to contact 101 or 999 services. One staff member told us, "I would get support from the person's family or call 999 if it was urgent." A family member told us, "They ring me if she is not well." 9 New Mabgate Centre Inspection report 12 September 2016
Is the service caring? Our findings In our survey, staff told us they were always introduced to people who used the service before working unsupervised with them. Health professionals told us staff were kind and caring towards the people who used the service. We asked staff about the care people received. Comments included, "Care is tremendous, and it has opened my eyes. It is overwhelming. You look after people how you would like to be looked after", "People are really well looked after", "People are looked after very well. They are cared for and their needs are considered" and "Care is smashing, people always look well dressed." A family member we spoke with told us, "They understand how to support [name of person]. It is a fabulous service and really excellent provision, one of the best." During our inspection we saw staff interactions with people at the New Mabgate Centre were relaxed and unrushed and were focussed on people's needs and activities. We observed and heard some good interaction and conversations between staff and people who used the service. In our survey, 86% of staff and all health professionals agreed care and support provided helped people who used the service to be as independent as they could be. 86% of staff also agreed people who used the service were always treated with respect and dignity by staff. On the day of our inspection we did not see or hear anything that would have comprised people's dignity. We asked staff about peoples' dignity. Comment included, "I respect people cultural needs", "When helping people with their personal care, and this is done sensitively. Dignity is respected", "Toilet door is always closed" and "We always check if we should go into the toilet with people or not." A family member told us, "As far as I am aware his dignity is respected and I am happy." 10 New Mabgate Centre Inspection report 12 September 2016
Is the service responsive? Our findings We asked in the PIR, 'What improvements do you plan to introduce in the next 12 months that will make your service more responsive, and how will these be introduced?' The provider stated 'Care plans to be made in person centred formats and service users to be provided with a copy, work started on this February 2016 - new format care plans will be produced over the coming 12 months following individuals annual review and will be overseen by service managers'. We saw work on completing the new care and support plan format had started with a completion day of Spring 2017. We saw the new care and support plan documentation included sections called 'my support plan' and 'about me'. The care and support plan was personalised and concentrated on individual needs, with guidance for staff to follow and people and/or family members were involved in decisions about the care and support provided. One staff member told us, "We are including the person much more and family members are involved. We ring them regularly." Another staff member said, "Family members are involved when appropriate." A family member told us, "I am fully keep informed about progress, they listen to me. The plan is very extensive and detailed." We saw evidence of care plans being reviewed regularly and we noted all the care and support plan documentation was in a pictorial format. Individual aims and goals had identified. Staff told us these had been agreed with each person following the assessment. The care and support plan reflected the needs and support required. We saw staff had a clear understanding of people's life histories, their interests and hobbies and how they had been supported to develop life skills to be more independent. We asked staff about the care and support plans. Comments included, "Care plans are very informative and give you a good idea about who that person is", "Care plans are good, you can find out a lot about them and their family history" and "Care plans are very detailed to the point of it been difficult to remember all the information." We saw a weekly individual timetable of events and routine and daily 'session planners' were completed for these events. One person's 'session planner' covered communication. This recorded how the person would develop these skills and which areas of the person's life this would support. For example, behaviour and daily living. Daily records, communications books and handover notes were completed by staff which demonstrated how people had spent their day. They recorded the person's behaviour, their physical and emotional wellbeing and what social activities they had attended. Staff demonstrated an in-depth knowledge and understanding of people's care, support needs and routines and could describe care needs provided for each person. We saw one care plan had a pictorial social stories book which explained day to day activities and events. Support was given for people to maintain their own independence and community involvement. They took part in activities they enjoyed. We saw people took part in a range of activities which included accessing the local and wider community. People had an activity programme and individual 'session planner' for each activity. 11 New Mabgate Centre Inspection report 12 September 2016
We asked staff about the activities people took part in. Comments included, "Activities are outstanding, and there is loads of variety. People enjoy what they do and you can tell with their expression and laughter", "The things people get to do and the places they go are really good. We are playing tennis today", "You can assess how much enjoyment people get out of each activity. Some people like horse riding or bowling, you can tell with their expression" and "We are going to Halifax on the train today. I can tell when people are enjoying the activity." A family member we spoke with told us, "The take her out and find things she would like to do and that she would be interested in. [Name of person] is doing really well and she is happiest she has ever been." In our survey, 71% of health professionals agreed the managers were accessible and approachable and dealt effectively with any concerns raised. We saw there was a complaints policy and procedure in place. We also saw information on how people or family members were able to make a complaint in the providers service user guide. We noted this was in a pictorial format. We saw compliments from the family member which included 'doing a brilliant job' and 'things are really moving on, LAS has done [name of person] the world of good. Thanks to all the staff'. A family member told us, "They address any concerns I have." We saw people were able to speak to staff and the acting team manager when they wished and it was clear there was an 'open door' policy at the service. One staff member told us, "Complaints are taken seriously." Another staff member said, "I would know who to go to and I know this would be addressed." 12 New Mabgate Centre Inspection report 12 September 2016
Is the service well-led? Our findings At the time of our inspection the service did not have a manager who was registered with the Care Quality Commission (CQC). The deputy chief executive told us they were currently in the process of recruiting a permanent manager and they would be registering them with the CQC once appointed. The acting team manager worked alongside staff overseeing the care given and providing support and guidance where needed. They engaged with people at the service and were clearly known to them. Discussions confirmed the management team had a good knowledge of people who used the service, their families and their individual needs. We saw staff attending the office appeared to have a relaxed and friendly relationship with all the management team. In our survey, staff and health professionals said they would recommend the service to a family member. One staff member told us, "I would put a family member into this service." 71% of staff told us managers asked them what they think about the service and take their views into account. Health professional agreed the service was well managed. Staff spoke positively about the management team and said they were happy working at the service. One member of staff said, "I feel supported. Staff have been outstanding. Senior managers are very organised, they are approachable and have an open door", "All the managers are approachable. I feel very supported. I am very happy, this is one of the best jobs I have ever had, and it is really friendly and a good service", "The manager does very well and is approachable. The management team are really good. I have no concerns and I love working here" and "Very approachable, they are not punitive and are interested in what I am doing, they are not aloof. I am quite happy." A family member we spoke with told us the management team were very helpful. They said, "The service is well managed and the management team are responsive and they listen, they keep me in the loop. It is an excellent service, best in the city." Systems were in place to monitor the quality and safety of the service. We saw a quality assurance report had been completed in 2015 and a pictorial summary report had been produced from the report. The summary report included areas looked at such as, meeting people's needs, communication and complaints, staff training and the environment. It also included an action plan for each section of the report. For example, 'we will make sure everyone knows about annual reviews' and 'we will monitor staff training to make sure the staff stay well trained'. We saw the managers weekly report was completed which included an overview of each person who used the service, staffing levels, new ideas, the environment and complaints. We asked in the PIR, 'What improvements do you plan to introduce in the next 12 months that will make your service better led, and how will these be introduced?' The provider stated, 'An audit tool has been devised which encompasses standards required by CQC, the local authority and the National Autism Society accreditation. Deputy chief executive is currently trying to engage service users in taking part in a quality action group meeting and it is hoped that people willing to attend have been identified by the end of the year.' We saw the new audit tool template included information about each person, staff and the 13 New Mabgate Centre Inspection report 12 September 2016
organisation. Action plans were also included. The chief executive told us the new audit tool would be implemented by the end of September 2016. We also noted the service was accredited with the National Autism Society in June 2015, which required the service to meet 15 core and 15 specialist standards. The acting team manager undertook a monthly monitoring audit of analysing incidents and accidents. They confirmed there were no identifiable trends or patterns in the last 12 months. We saw staff meetings were held on a monthly basis which gave opportunities for staff to contribute to the running of the service. We saw the staff meeting minutes for April 2016 and discussions included compliments, health and safety, housekeeping and communication. We also saw 'quality action group' meeting minutes from May 2016 which included discussions about funding and finance, day services and residential services. We saw parents and health professionals had been sent questionnaires in October 2014. We noted the majority of answers stated agree or strongly agree to the questions asked. The chief executive told us questionnaires were due to be sent out again in September 2016. Our observations during our inspection showed the service was person centred, inclusive and there was a positive approach to people's care and support. 14 New Mabgate Centre Inspection report 12 September 2016